203 - Lampiran 1. Formulir Klaim Rawat Jalan Rehab Medik [PDF]

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PEMERINTAH KABUPATEN SUKOHARJO



RUMAH SAKIT UMUM DAERAH Jalan dr. Muwardi Nomor : 71 Sukoharjo, Kode Pos : 57514 Telp. (0271) 593118/Fax (0271) 593005 Sukoharjo Website: rsud.sukoharjokab.go.id., E-mail : [email protected]



Formulir Klaim Rawat Jalan Layanan Kedokteran Fisik dan Rehabilitasi I. Diisi oleh Pasien / Peserta No RM / Reg : Nama Pasien : ............................................................................................................ Tanggal Lahir



.... : .............................................................................................................



Alamat



.... : .............................................................................................................



Rujukan dari



.... : .............................................................................................................



Dokter Tanggal Rujukan



.... : ............................................................................................................. ....



II. Diisi oleh Dokter SpKFR  Tanggal Pelayanan



: .............................................................................................



 Tanggal ke DPJP Pengirim



... : ...........................................................................................



 Diagnosis



. : ........................................................................................... . ...........................................................................................



 Frekuensi Tindakan /Siklus



. : ...........................................................................................



 Goal



. : ...........................................................................................



 Tindakan



. : ...........................................................................................



. ........................................................................................... . ........................................................................................... . Ya (.................................................................)



 Suspek Penyakit Akibat Kerja :



Tanda Tangan Pasien



(.......................................................)



Tidak



Sukoharjo, ........................................... Dokter



(.......................................................)



PEMERINTAH KABUPATEN SUKOHARJO



RUMAH SAKIT UMUM DAERAH Jalan dr. Muwardi Nomor : 71 Sukoharjo, Kode Pos : 57514 Telp. (0271) 593118/Fax (0271) 593005 Sukoharjo Website: rsud.sukoharjokab.go.id., E-mail : [email protected]



No. RM



: ........................................................................................................................



Nama Pasien



: ........................................................................................................................



Diagnosa



: ........................................................................................................................



Permintaan Terapi :



TTD PROGRAM 1. 2. 3.



TANGGAL



PASIEN



DOKTER



TERAPIS



4. 5. 6. 7. 8. 9. 10.